Surgical Privileges Form Orthopedic Surgery - qchp.org.qa · PDF fileSurgical Privileges Form Orthopedic Surgery ... 6.Surgical treatment of special hand infections (Palmer spaces,

Name of applicant………………

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Surgical Privileges Form

Orthopedic Surgery

CLINICAL PRIVILEGES REQUEST

Applicant’s Name: …………………………….…… . Scope of Practice: ……………………….

License No. (If Any): …………………………….…… .. Facility:………………………… ..........

Date: …………………………….………………………….. Place of Work: …………………...................

Requested Recommended Not

Privileges (To be completed (For committee use) Recommended by the applicant) (For committee use)

CATEGORY I: CORE PRIVILEGES

1. Admitting Privileges 2. Admission history and physical examination

3. Interpretation of laboratory tests

4. Insertion of urinary catheters

5. Peripheral intravenous catheter insertion

6. Nasogastric tube insertion

7. Oropharyngeal airway insertion

8. Prescribing Oxygen therapy

CATEGORY II: EMEREGENCY SURGERY

1.Application of Traction Pins 2.Closed manipulation of fractures /

dislocations/splints/casts

/ splints / casts

3.Closed manipulation and Percutaneous wire /

screw fixation

4.Open reduction with plate / screw fixation

(MIPO + LISS)

5.Open reduction and tension wiring

6.Open reduction with intramedullary device

7.Closed reduction with intramedullary device

8.Open reduction and application of external

fixation

9.Closed reduction and Application of external

fixation

10.Use of Hybrid External Fixator (Illizarov)

11.Operative treatment of intra articular fractures

12.Operative treatment of Soft Tissue Injuries

13.Tendon / ligament repair

14.Fasciotomy

15.Wound debridement

16.Operative treatment of Acute bone, joint &

Soft tissue infection


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17.Bone grafting

18.Split thickness skin graft (STSG)

19.Hemi / Bipolar Arthroplasty of Hip Fractures

20.Operative fixation using DHS / DCS /

Cannulated screws

CATORGY III: PEDIATRIC SURGICAL PRCOEDURES

Upper Extremity

1.Correction of forearm deformities (e.g

hypoplasia of radius, Madelung’s deformity)

2.Correction of elbow deformities (e.g

congenital dislocation head of radius, Cubitus

Varus)

3.Correction of shoulder deformities (e.g

Sprengel’s Deformity)

4.Soft tissue release of the thumb or hand in CP

5.Tendon transfer to the elbow, hand or wrist

6.Release of congenital trigger fingers in

children

Hip Joint

1.Close reduction, spica for DDH 2.Arthrography of the hip

3.Percutaneous tenotomy, close reduction of the

hip

4.Extensive soft tissue release of the hip

(neuromuscular disorders)

5.Open reduction of the hip for DDH

6.Open reduction of the hip, femoral osteotomy

7.Pelvic osteotomies (Salter, Pemberton, Chiari,

etc.)

8.Fixation of slipped epiphysis

9. 3-plane intertrochanteric osteotomy of femur

Knee Joint

1.Manipulation, POP for congenital dislocation

of the knee

2.Soft tissue release for congenital dislocation of

the knee

3.Soft tissue release for fixed flexion deformity

(neuromuscular)


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4.Supracondylar osteotomy of femur 5.Osteotomies of the proximal tibia

6.Procedures for recurrent dislocation of patella

7.Arthroscopy for pediatric knee

Foot and ankle

1.Manipulation, POP for clubfoot

2.Posterior release for clubfoot or spastic

equines deformity

3.Postero-medial release for clubfoot

4.Bony procedures to correct residual

deformities

5.Soft tissue release, open reduction for vertical

talus

6. Tendon transfer to the foot

7.Calcaneal osteotomies

8.Extra- articular subtalar fusion

9.Supramalleular osteotomy

Lower limb

1. Epiphysidesis

2. Lengthening osteotomies of femur or tibia

3. Correction of deformities or length

discrepancies with illizarov instrumentation

Bone tumors

1

.

1. Excision of osteochondroma

2

.

2. Excision of osteoid osteoma

3. Curettage of bone cyst or tumor and bone

grafting

Miscellaneous

1.Correction of long deformities in osteogenesis

imperfect

2.Drainage of an infected joint (e.g hip,

shoulder, ankle, knee)



Name of applicant……………

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CATEGORY IV: SPINAL SURGERY

1.Local injections: Facetal, Epidural (Caudal),

Perivertebral

2.Lumbar Disectomy

3.Decompressive Lam inectomy

4.Posterolateral (Intratransverse) fusion

5.Posterior spinal fusion with instrumentation

(Diapson)

6.Posterior lumbar Interbody fusion

7.Anterior lumbar interbody fusion

8.Corpectomy and Anterior fusion

9.Correction of spinal deformity with posterior

instrumentation

10.Correction of spinal deformity with anterior

instrumentation

11.Combined Anterior and Posterior correction of

spinal deformity

spinal deformity

12.Surgical correction of equinus deformity in CP

13.Kyphoplasty and vetebroplasty

14.Some thorascopic spinal surgeries

15.Some mini-invasive spine surgeries


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CATEGORY V: SHOULDER SURGERIES

1.Manipulation of frozen shoulders 2.Subacromial and Intraarticular injections

3.Scapular bursa injection: excision – open

4.Scapular bursa injection: arthroscopic

5.Shoulder arthroscopy: diagnostic

6.Shoulder arthroscopy: synovial biopsy

7.Shoulder arthroscopy: lose bodies

8.Shoulder arthroscopy: slap lesions

9.Subacromial decompression: open

10.Subacromial decompression: arthroscopic

11.A/C joint resection: acromioplasty open

12.A/C joint resection: arthroscopic

13.Anterior shoulder stabilization procedures:

open

14.Anterior shoulder stabilization procedures:

arthroscopic

15.Posterior shoulder stabilization: open

16.Shoulder replacement

17.Rotator cuff repair: open

18.Rotator cuff repair: arthroscopic

19.Biceps tendon tenodesis open

20.Subscapular Nerve entrapment release

21.Soft tissue / Bony tumors around shoulder:

excision

22.Soft tissue / Bony tumors around shoulder:

Biopsy

23.Shoulder Arthrodesis

24.ORIF of fractures of scapula

25.ORIF of fractures of humeral head / humeral

shaft


Privileges (To be completed

by (For committee use) Recommended

the applicant) (For committee use)

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CATEGORY VI: WRIST AND HAND SURGERY

1.Arthrodesis of the Wrist

2.Arthroscopy of the Wrist

3.Tendon Repair Basic Techniques

4.Nerve Entrapment surgery (Medial Nerve,

Ulnar nerve)

5.Surgical treatment of Tenosynovitis

6.Surgical treatment of special hand infections

(Palmer spaces, web spaces … etc)

7.Surgical treatment of tendon sheets infection

8.Carpal ligament instability (repair &

reconstruction)

9.Surgical treatment of Carpal bones non union

10.Surgical treatment of Arthritic Wrist and

hand(proximal) row carpectomy, radial & ulnar

shortening and lengthening Savue – Kapandji,

limited Arthrodesis triscaphoid, STT)

11.Stabilization of the DRUJ

12.Surgery for the TFCC Pathology

13.Trigger finger, Mallet Finger, Dequarvian

(stenosing tenosynovitis)

(stenosing Tenosynvoitis)

14.Dupuytren Release

15.CM CJ, M CPJ, IPJ Replacement, and ligament

repair.

Repair

CATEGORY VII: PELVIS AND HIP SURGERY

1.Closed reduction with clamp / Fix Pelvic Ring

disruptions

2. Fixation of Pelvic Ring Disruptions with S.I.

Screws / Plates

3.Fixation of Acetabular fracture through

inoinguinal Approach

4.Fixation of Acetabular fracture through

Kocher – Lanenaeck Approach

5.Fixation of A cetabular fracture through

extensile iliofermal approach

6.Periacetabular osteotom y (Adult)

7.Proximal femoral osteotomy (Adult)

8.Arthrodesis of hip joint

9.Cemented total Arthroplasty of Hip

10.Cementless total Arthroplasty of Hip

11.Surface Replacement / Hybrid Athroplasty of

Hip






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CATEGORY VIII: KNEE SURGERY

1.Aspiration of Knee

2.Arthroscopic diagnostic

3.Arthroscopic

washout/debridement/Biopsy/Rem. LB

4.Arthroscopic surgery of menisci

5.Arthroscopically assisted repair /

reconstruction of cruciate ligaments

6.Arthroscopic synovectomy

7.Open repair of collateral ligaments

8.Repair of complex ligamentous disruptions

9.Operative treatment of patellar instability

10.Supracondylar fem oral osteotomy

11.High tibial osteotomy

12.Athrodesis of knee

13.Total condylar arthroplasty of knee

14.Unicondylar Arthroplasty of knee

15.Revision arthroplasty of knee

CATEGORY IX: FOOT AND ANKLE SURGERY

1.Arthrodesis of the Ankle (Triple Arthrodesis,

limited, big toe fusion)

2.Surgical treatment of Acute and chronic Ankle

instability

3.Ankle arthroscopy

4Surgical decompression of Impingement Syndrome

5.Surgical treatment of Tarsal Coalition

6.Removal, excision of soft tissue swelling and

Mortin’s neuroma

7.Hallux Valgues surgery (soft tissue

procedures, Fusion, Excision Arthroplasty,

osteomies proximal and distal)

8.Surgery of Pes Planus and Pes Cavus

12.Revision Arthroplasty of Hip

13.Complex Arthroplasty of Hip (Acetabular

Augmentation)

14.Open procedures on Femoral Head





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9.Surgery of Hammer toes, claw Toes and

mallet toes, soft tissue and bony procedure

10.Surgical treatment of Ankle Tendons and

fascia (Posterior and anterior Tibial, Peroneal

and Achilles Tendon, planter fascia pathology)

11.Ingrown toenail operation

12.Lesser toe fusion 13.Calcaneal spur excision

14.Steidler operation for foot

CATEGORY X: Amputations

Upper Extremity

1. Disarticulation at Shoulder

2.Transarticular Amputation of Elbow 3.Amputation of Elbow

4.Amputation of Wrist 5.Amputation of Hand

6.Amputation of Digits

Lower

1. Disarticulation at Hip

2. Transarticular Amputation of Knee 3. Fore / Hind Quarter Amputation

4.Above Knee Amputation

5.Below Knee Amputation

6.Amputations around Ankle

7.Amputations through Tarsus

8.Amputations through Metacarpals /

Metatarsals

9.Ray Amputations

10.Amputations/ Terminalisations through

Phalanges

11.Soft tissue release around hip, knee, ankle and

foot in CP

12.Graf method for diagnosis of DDH with USG






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CATEGORY XI: ADDITIONAL PRIVILEGES (not included above)

Note: If additional privilege(s) are desired, please indicate this in the space provided above. You must submit

along with this application a necessary document(s) to support your request. If documentation is incomplete,

your request will not be accepted.

By signing below, I acknowledge that I have read, understand, and agree to abide by QCHP standards for

privileging. I have requested only those privileges for which by education, training, current experience and

demonstrated performance I am qualified to perform and wish to exercise, and I understand that:

a) In exercising any clinical privileges granted, I am constrained by QCHP's policies and rules applicable

generally and any applicable to the particular situation.

b) Any restriction on the clinical privileges granted to me is waived in an emergency situation and in such

situation my actions are governed by the recognized policies and rules.

………………………………………………….. …………………………

Applicant’s signature (Stamp if any) Date

………………………………………………….. …………………………

1. Medical Director (of the facility the applicant Date will perform surgeries in) Stamp & Signature

………………………………………………….. …………………………


………………………………………………….. …………………………






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For Committee use only

Evaluation Committee Chairman:

I have reviewed the requested clinical privileges and supporting documentation for the above-named applicant and

I have made the above-noted recommendation(s).

………………………………………………….. …………………………

Chairperson’s Stamp & signature Date

Other Committee Members:

………………………………………………….. …………………………

1) Name Date

………………………………………………….. …………………………

2) Name Date

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Surgical Privileges Form Orthopedic Surgery - qchp.org.qa · PDF fileSurgical Privileges Form Orthopedic Surgery ... 6.Surgical treatment of special hand infections (Palmer spaces,